Improved performance of new prenotification criteria for acute stroke patients.

BACKGROUND/PURPOSE: We aim to evaluate the accuracy of the new prehospital notification criteria for patients with potential acute stroke in the prehospital setting. METHODS: We conducted a retrospective observational study from March 2011 to February 2013 of potential acute stroke patients prenotified using the new criteria which were: (1) positive Cincinnati Prehospital Stroke Scale (CPSS); (2) symptom onset within 3 hours; and (3) blood glucose level > 60 mg/dL. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the new criteria were calculated and outcomes of acute stroke patients were reported. Data of all patients with stroke or transient ischemic attack (TIA) transported to the destination hospital were also obtained to evaluate the compliance of emergency medical technicians. RESULTS: There were 2888 patients suspected of stroke by emergency medical technicians and 221 patients prenotified due to meeting the criteria. The PPV, NPV, sensitivity, and specificity of the new criteria were 76.9%, 96.6%, 64.9%, and 98.1%, respectively. Onset time > 3 hours (24/51, 47.1%) and seizure (27.5%) were the two most common conditions leading to false prenotification. Of all prenotified patients, 23.1% (51/221) received thrombolytic therapy. Hemorrhagic stroke or ischemic stroke with hemorrhagic transformation (53.8%) and minor symptoms or rapid recovery (26.9%) were the most common reasons excluding correctly prenotified patients from thrombolytic therapy. CONCLUSION: The accuracy of the new prehospital stroke criteria has higher PPV and specificity compared to previous CPSS validation studies.

Stroke code improves intravenous thrombolysis administration in acute ischemic stroke.

BACKGROUND AND PURPOSE: Timely intravenous (IV) thrombolysis for acute ischemic stroke is associated with better clinical outcomes. Acute stroke care implemented with "Stroke Code" (SC) may increase IV tissue plasminogen activator (tPA) administration. The present study aimed to investigate the impact of SC on thrombolysis. METHODS: The study period was divided into the "pre-SC era" (January 2006 to July 2010) and "SC era" (August 2010 to July 2013). Demographics, critical times (stroke symptom onset, presentation to the emergency department, neuroimaging, thrombolysis), stroke severity, and clinical outcomes were recorded and compared between the two eras. RESULTS: During the study period, 5957 patients with acute ischemic stroke were admitted; of these, 1301 (21.8%) arrived at the emergency department within 3 h of stroke onset and 307 (5.2%) received IV-tPA. The number and frequency of IV-tPA treatments for patients with an onset-to-door time of <3 h increased from the pre-SC era (n = 91, 13.9%) to the SC era (n = 216, 33.3%) (P<0.001). SC also improved the efficiency of IV-tPA administration; the median door-to-needle time decreased (88 to 51 min, P<0.001) and the percentage of door-to-needle times ≤60 min increased (14.3% to 71.3%, P<0.001). The SC era group tended to have more patients with good outcome (modified Rankin Scale ≤2) at discharge (49.5 vs. 39.6%, P = 0.11), with no difference in symptomatic hemorrhage events or in-hospital mortality. CONCLUSION: The SC protocol increases the percentage of acute ischemic stroke patients receiving IV-tPA and decreases door-to-needle time.

Utilization of emergency medical service increases chance of thrombolytic therapy in patients with acute ischemic stroke.

BACKGROUND/PURPOSE: To determine whether utilization of emergency medical service (EMS) can increase use and expedite delivery of the thrombolytic therapy in acute ischemic stroke patients. METHODS: We analyzed consecutive patients presenting to the emergency department (ED) with an ischemic stroke within 72 hours of symptom onset from a prospective stroke registry. Variables associated with early ED arrival (within 3 hours of stroke onset) and administration of intravenous thrombolytic therapy were analyzed. RESULTS: From January 1, 2010 to July 31, 2011, there were 1081 patients (62.3% men, age 69.6 ± 13 years) included in this study. Among them, 289 (26.7%) arrived in the ED within 3 hours, and 88 (8.1%) received thrombolytic therapy. Patients who arrived at the ED by EMS (n = 279, 25.8%) were independently associated with earlier ED arrival (adjusted odds ratio = 3.68, 95% confidence interval = 2.54-5.33), and higher chance of receiving thrombolytic therapy (adjusted odds ratio = 3.89, 95% confidence interval = 1.86-8.17). Furthermore, utilization of EMS significantly decreased onset-to-needle time by 26 minutes in patients receiving thrombolytic therapy. CONCLUSION: Utilization of EMS can not only help acute ischemic stroke patients in early presentation to ED, but also effectively facilitate thrombolytic therapy and shorten the onset-to-needle time.

Factors associated with use of emergency medical services in patients with acute stroke.

PURPOSES: The aim of this study was to investigate the factors associated with use of emergency medical services (EMS) in patients with acute stroke. METHODS: Prospective data on consecutive patients with acute stroke who presented to the emergency department of a university medical center from January 1, 2010, to July 31, 2011, were analyzed. Patients were excluded if they had an unknown residence, had onset of stroke at a nursing home or hospital, or were transferred from another hospital. Variables for all patients with stroke and ischemic stroke who did and did not use EMS were compared. RESULTS: In total, 1344 patients (60% male; mean age, 68.7 years) were included. Use of EMS (n = 409; 30.4%) was significantly associated with a higher level of education (≧6 years vs <6 years; odds ratio [OR], 1.69; 95% confidence interval [CI], 1.25-2.29), a higher National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.05-1.11), altered consciousness (OR, 1.88; 95% CI, 1.25-2.84), and atrial fibrillation (OR, 2.43; 95% CI, 1.71-3.44) after adjustment. For patients with ischemic stroke, use of EMS was significantly higher in cases of cardioembolism (OR, 3.04; 95% CI, 1.40-6.60) and large artery atherothrombosis (OR, 2.10; 95% CI, 1.22-3.62) than lacunar infarction. CONCLUSION: Patients with stroke who have altered consciousness, a higher level of education, a higher National Institutes of Health Stroke Scale score, atrial fibrillation, and cardioembolic stroke were more likely to use EMS.

Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit.

Dysphagia increases the risk of pneumonia in stroke patients. This study aimed to evaluate bedside swallowing screening for prevention of stroke-associated pneumonia (SAP) in acute stroke patients admitted to the intensive care unit (ICU). Consecutive acute stroke patients admitted to the stroke ICU from May 2006 to March 2007 were included. Patients were excluded if they were intubated on the first day of admission or had a transient ischemic attack. A 3-Step Swallowing Screen was introduced since October 2006 and therefore patients were divided into pre-screen and post-screen groups. A binary logistic regression model was used to determine independent risk factors for SAP and in-hospital death. There were 74 and 102 patients included in the pre- and post-screen groups, respectively. Pneumonia was associated with higher National Institutes of Health Stroke Scale (NIHSS) score, older age, nasogastric and endotracheal tube placement. After adjusting for age, gender, NIHSS score and nasogastric and endotracheal tube insertion, dysphagia screening was associated with a borderline decrease in SAP in all stroke patients (odds ratio, 0.42; 95% CI, 0.18-1.00; p=0.05). However, dysphagia screening was not associated with reduction of in-hospital deaths. Systematic bedside swallowing screening is helpful for prevention of SAP in acute stroke patients admitted to the ICU.